Michael Kaye

Acquired Insulin Resistance: A Case Report

Insulin resistance, usually denned as a condition in which a diabetic requires a dosage of insulin in excess of 200 units daily, is uncommon. Most of the reported cases have been associated with diabetic keto-acidosis, allergy to insulin, or a variety of other diseases. The following case is reported because none of these conditions was present and the opportunity for detailed investigation was possible. This disclosed, among other things, the presence of an insulin-neutralizing factor in the patients serum. ;

Hemodialysis Neutropenia and Dialyzer Reuse: Role of the Cleansing Agent

As part of a study to evaluate the safety and efficacy of dialyzer reuse, a comparative study of two methods of dialyzer reprocessing, manual and automated, was conducted. Five stable end-stage renal disease patients on center hemodialysis were evaluated as to hematological and metabolic parameters throughout two series of three consecutive dialyses using first new and then reused dialyzers reprocessed according to each of the two methods. New dialyzers and reused dialyzers following automated reprocessing always induced a profound fall in circulating neutrophil counts shortly after the start of dialysis. Hemodialysis neutropenia was not observed, however, with reused dialyzers reprocessed manually unless the concentration of sodium hypochlorite (bleach) employed was made equal to that required in automated reprocessing by being raised from 1.0 to 4.3%. It would be reasonable to conclude from these results that among the various differences between the two dialyzer reprocessing methods, restoration of the original level of biocompatibility of the reused dialyzers membrane is related to the concentration of the cleansing agent.

Aging, Circadian Weight Change, and Nocturia

Background: Normal young individuals excrete more sodium in their urine during the day than overnight, but the reverse occurs in older individuals with nocturia. The reason is unknown. Methods: First, a self-study was performed, determining the relation between morning and night weight change as an index of volume expansion. This was followed for 1 year and modified, in separate experiments, by assessing either a diuretic (furosemide 40 mg) or recumbency. Weight and in some instances ankle circumference were measured, and day and night urines collected. Second, a community study of 102 individuals was done, measuring circadian weight change and nocturia for 3 days in each subject. Third, measurement of day and night urine electrolytes and weight change was performed in 10 non-nocturics and 12 matched nocturics (age ≧60 years). Results: Salt and water retention occurs during the day and natriuresis and diuresis overnight. Nocturia occurs when weight gain is greater. It is prevented by an afternoon diuretic or daytime recumbency. Conclusions: Idiopathic nocturia is due to daytime volume expansion associated with the upright position. It is hypothesized that this is caused by sodium retention during the day mediated by renal nerve sympathetic activity which together with angiotensin II acts on the kidney to increase tubular sodium reabsorption either directly or by reducing daytime glomerular filtration rate.

Consent to Dialyzer Reuse: Is It Ethically Necessary?

It is argued that consent by the patient to reuse dialyzers which have been mechanically cleansed is not required provided adequate standards of practice and safety are utilized. Based on medical benefits, administrative order and cost saving we propose that specific informed consent for such reuse should not be mandatory and that it could at times be unhelpful, both to care givers and recipients.

When and How Should Calcitriol Be Used in Dialysis Patients

1 . Malluche HH, Monier-Faugere M-C: Changing spectrum of renal bone-disease over the last decade. Nephrol Dial Transplant 9:911, 1994 2. Brown EM, Gamba G, Riccardi R, Lombardi M, Butters R, Kifor 0, Sun A. Hediger MA, Lvtton I, Hebert J: Cloning and characterization , of an extracellular Ca 2 +-sensing receptor from bovine parathyroid. Nature 36657S-580. 1993 3. Silver J , Modem E, Epstein E, Kilav R, Naveh-Many T: New aspects in the control of parathyroid hormone secretion. Curr Opin Nephrol Hypertens 3:379-385. 1994 4. LBwik LWGM. Nibbering PH, van de Ruit M, Papapoulos SE: Inducible production of nitric oxide in osteoblast-like cells and in fetal mouse bone explants is associated with suppression of osteoclastic bone resorption. J Clin Inverf 93: 1465-1472. 1994 5. Heyer U, Hagemann J , Asmus G, Rohrich B , Pliier M, von Herrath D, Schaefer K: Intact serum parathyroid hormone as a predictor for hypercalcemia in henodialysis patients receiving calcitriol and calcium acetate. A prospective study. J Nephrol7:218-221, 1994 6. Ghazali A, Hamida FB, Bouzernidj M, Esper NE, Westeel PF, Fournier A: Management of hyperphosphatemia in patients with renal failure. Curr Opin Nephrol Hypertens 2566-579, 1993 7. Schaefer K: Unsatisfactory control of serum phosphate: Why is it so common and what can be done? Nephrol Dial Transplant 9:13661367, 1994 8. Brancaccio D, Gallieni M: Recent advances in intravenous calcitriol treatment. Curr Opin Nephrol Hypertens 3:411416, 1994 9. Herrmann P, Ritz E, Schmidt-Gayk H, Schafer I, Geyer I, NonnastDaniel B, Koch K-M, Weber U, HBrl W, Haas-Work A, Kilhn K, Bierther B, Schneider P: Comparison of intermittent and continuous oral administration of calcitriol in dialysis patients: A randomized prospective trial. Nephron 67:48-53, 1994

Triage and the patient with renal failure

SIR Drs Parsons and Lock are to be congratulated for their important study published in the December I980 issue of JME where they examined the causes for rejection from entry to dialysis programmes and find that experienced nephrologists are unable to agree on the criteria for rejection and one individual was unable to reject anyone! We have developed the practice of accepting almost everyone who wishes to be treated and then if their subsequent course is unfavourable consider discontinuing treatment if the patient and/or family are in agreement. The reason for this approach has been suggested in this paper, namely that while it is possible in many patients to foresee how they will fare there is a significant number in whom ones predictions are totally incorrect. The patient therefore must be given the benefit of the doubt as is done in other branches of medicine. What I find disturbing in both the editorial comment and the paper on cost-benefit analysis in the same issue is the tacit assumption that dialysis units in Britain will of necessity have to carry on with the selection because offiscal constraints. For a developed country that spends millions of pounds on tobacco, alcohol, armaments etc. and has extraordinary revenue from North Sea oil coldy to deny the opportunity for life to this group of patients has to be seen as inhumane and unethical. The solution is clearly a political rather than medical one and may only be remedied by the force of public opinion. MICHAEL KAYB Division of Nephrology Montreal General Hospital and the Faculty of Religious Studies, McGill University, Montreal, Quebec, Canada